1. A Young Man with Unilateral Proptosis
Presented by:
Dr. Md. Kamal Hossen
Asstt. Registrar
Dept. of Neurosurgery, MMCH

2. “A Young Man with Unilateral Proptosis”

3. Chairperson Prof ( Dr.) M A Gafur Miah Professor & Head Department of Surgery Mymensingh Medical College Coordinator Dr Saumitra Sarkar Assistant Professor & Head Deptt. of Neurosurgery Mymensingh Medical College

4. Particulars of the patient

5. Particulars of the Patient:
Name : Md. Shafayet
Age : 27 years
Sex : Male
Religion : Islam
Address :Purbadhola, Netrokona
Marital status : Unmarried
Occupation : Unemployed
Date of admission : 21st November 2011
Date of examination : 21st November 2011

6. Presenting complaints : (Pre-Operative)
Irritation and watering of the left eye for 10 month.
Forward displacement of left eye ball for 3 months
Gradual dimness of vision in left eye for 3 months

7. History of present illness :-
According to the statement of the patient he was reasonably well about 10 months back. Then he complained about irritation and watering of the left eye which was prominent in day time. In last 3 months he developed forward displacement of left eye ball,

8. History of present illness :-
which was gradually increasing and not associated with pain and pulsation. He also complained gradual dimness of vision in left eye and occasional double vision for 3 months.

9. History of present illness (Cont.)
Patient had no history of Headache, vomiting, vertigo, fever, night sweats, weight loss, cough or haemoptysis, haematuria or per rectal bleeding, bone pain. There was no history of trauma.

10. H/O of Past illness – The patient has a history of jaundice 2 years back.
Personal history – The patient is a smoker. He took 5 sticks per day .

11. Immunizations History – Completed immunization.
Family history – No such diseases found in the other family members.

12. Treatment History
At first he was treated by Ophthalmologist at BNSB, Mymensingh for watering and irritation and he used eye drop and took some medicine for his illness but he couldn’t mention any name. Then he got treatment at Dr. Muktadir Eye Hospital, Gauripur and After doing the CT scan, the patient was referred to a Neurosurgeon of Dhaka. But, according to the advise of a physician he got admitted in the Neurosurgery dept. of MMCH.

13. General Examination (Preoperative)
Appearance – ill looking
Body build – Average
Anemia – Absent
Cyanosis – Absent
Jaundice – Absent
Oedema – Absent
Dehydration – Absent
Lymph nodes – not palpable
Thyroid gland – not enlarged
Neck vein – not engorged
Clubbing – Absent
Koilonychia – Absent
Leukonychia – Absent
Pulse – 76/min
B.P – 130/80 mm of Hg
Temp – Normal
Respiration – 16/min

14. Local Examination (Preoperative)
Local Examination of the Left Eye
- Inferonasal globe displacement and fullness of the superotemporal lid and orbit.
- Proptosis – 4 mm
- A S-shaped contour to the upper lid.
- Tenderness absent.
- Motility of the left globe restricted in superior and lateral direction.
- Intraocular pressure (IOP)- Not measured
- Preauricular lymphadenopathy - Absent

15. Systemic examination (Preoperative)
Nervous system examination –
Higher Psychic function – Normal
Speech – Normal
Gait – Normal

16. Systemic examination (Preoperative)
Nervous system examination –
Examination of cranial nerve
Olfactory nerve – sense of smell is intact
Optic nerve – Visual acuity : 6/6 (Rt) Finger counting at 2 feet (Lt)
Field of vision : reduced
Color vision : normal
Ophthalmoscopic examination :
Disc swelling on left eye
Light reflex : normal

17. Systemic examination (Preoperative)
Nervous system examination –
Oculomotor nerve : normal
Trochlear nerve : normal
Abducent nerve : normal
Trigeminal nerve : normal
Facial nerve : normal

18. Systemic examination (Preoperative)
Nervous system examination –
Vestibule-cochlear nerve : normal
Glossopharyngeal nerve : normal
Vagus nerve : normal
Accessory nerve ( spinal part) : normal
Hypoglossal nerve : normal

19. Systemic examination –
Motor function
Upper limbs – Lt Rt.
Bulk of muscle – Normal Normal
Tone of muscle – Normal Normal
Muscle Power – Grade ‘5` G - 5
Lower limbs – Lt Rt.
Bulk of muscle – Normal Normal
Tone of muscle – Normal Normal
Muscle Power – Grade ‘5` G - 5

20. Systemic examination –
Co ordination of movement :
Finger nose test – intact
Heel shin test – intact
Involuntary movement : absent

21. Systemic examination –
Jerks
All jerks are Normal
Planter response: Flexor (B/L)
Clonus- Absent (B/L)

22. Systemic examination –
Sensory function test :
Pain, touch, temperature – intact
Joint position sense – intact
Vibration sense – intact
Autonomic function
Normal

23. Systemic examination –
Signs of meningeal irritation :
Neck rigidity : absent
Kerning’s sign : negative
Brudzinski’s sign : negative

24. Systemic examination –
Cardiovascular system
Nothing abnormalities are detected
Respiratory system
Alimentary system

25. Salient Feature

26. Salient feature
A young man, 27 years of age right handed hailing from Purbadhola, Netrogona presented with irritation and watering of the left eye for 10 months, forward displacement of left eye ball for 3 months and gradual dimness of vision in left eye for 3 months.

27. Salient feature (Cont.)
He complained about irritation and watering of the left eye which was prominent in day time. In last 3 months he noticed forward displacement of left eye ball which was gradually increasing and not associated with pain and pulsation. He also complained gradual dimness of vision in left eye and occasional double vision .

28. Salient feature (Cont.)
The patient had no history of Headache, vomiting, vertigo, fever, night sweats, weight loss, cough or haemoptysis, haematuria or per rectal bleeding, bone pain. There was no history of trauma.

29. Salient feature (Cont.)
On examination, the patient was ill looking and his pulse was 76/min & BP was 130/80 mm Hg . On local examination of the left eye he was found Inferonasal globe displacement and fullness of the superotemporal lid and orbit with 4mm proptosis of left eye and A S-shaped contour to the left upper lid. Tenderness was absent. The motility of the left globe restricted in superior and lateral direction with absent preauricular lymphadenopathy.

30. Salient feature (Cont.)
He was found with visual acquity 6/6 (Rt), finger counting from 2 feet (Lt) & with restricted field of vision. He was found disc swelling in left eye.

31. Provisional Diagnosis
Left sided Retrobulbar Benign Tumour

32. Diferential Diagnosis
Pseudotumour
Malignant Retrobulbar tumour
Carotido- Cavernous Fistula
Orbital vein thrombosis
Haemangioma
Neurofibroma
Optic Nerve Glioma

33. Investigation

34. Investigations (Preoperative)
CBC :
TC – 10,300/cmm
DC – N 68%
L 26%
M 02%
E 04%
Hb% - 12 gm/dl
ESR – 18 mm in 1st hour

35. Investigations (Cont…)
Serum creatinine mg/dl
RBS- 5.4 mM/L
Urine R/M/E- Normal
ECG – Within normal limit
CXR P/A - Within normal limit

36. CT Scan of Brain

43. Clinical Diagnosis

44. Retrobulbar solid tumour on left orbit
Clinical Diagnosis
Retrobulbar solid tumour on left orbit

45. Treatment

46. Treatment
Transcranial Orbitotomy and Removal of the Tumour was done under G/A on 11th December, 2011

47. Operative Procedure

55. Confirm Diagnosis by Histopathology
Pleomorphic Adenoma